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Less Is (Usually) More: When Is Amputation Appropriate for Treatment of Extremity Soft Tissue Sarcoma?

Department of Surgery, University of Washington, Box 356410, 1959 N.E. Pacific Street, Seattle, Washington 98195

Correspondence: Address correspondence and reprint requests to: Gary N. Mann, MD; E-mail: gnmann{at}u.washington.edu.

Limb-salvage surgery, combining wide excision and radiotherapy, is the standard of treatment for patients with extremity soft tissue sarcoma. In the only randomized study comparing amputation with limb preservation, Rosenberg et al.¹ demonstrated that despite slightly higher local recurrence rates, limb salvage was not detrimental to patient survival. This is a common finding in solid tumor biology: organ preservation is not associated with worse overall survival, even though patients often have more local recurrences. Indeed, breast-conservation therapy is preferred over mastectomy and has been proven to be as effective in multiple randomized studies.² We also see this, for example, in such diverse tumors as laryngeal cancer³ and anorectal melanoma.⁴ This trend of "less is more" in surgery is well founded and leads to improved patient satisfaction and quality of life (QOL) without compromising quantity of life.

In this issue of Annals of Surgical Oncology, Ghert et al. ⁵ from the Princess Margaret Hospital present a series of patients undergoing amputation as the primary surgical procedure for treatment of extremity soft tissue sarcoma. In their prospective database, they found that only 6% of patients (25 of 413) required amputation as initial surgical treatment. This is in keeping with data from other institutions, where the rates of initial amputation have decreased from approximately 40% to approximately 5% as more effective surgical and oncological strategies evolve and as our understanding of the natural history of these malignancies improves. There is still a role for amputation, and in this series there were three major indications: (1) anticipated inadequate limb function after wide excision, (2) multicompartmental neurovascular tumor involvement, and (3) local tumor contamination from unplanned prior surgery. Although local recurrences were not discussed in either patient group, one would expect lower rates of local relapse in those undergoing amputation.¹ Despite this expectation, on univariate analysis, patients undergoing amputation had higher rates of systemic relapse, which on multivariate analysis was accounted for by the larger tumor size in these patients. As alluded to previously, more radical surgery does not seem to improve survival.

With this in mind, the limits of limb-sparing surgery are pushed to their maximum. Larger and deeper tumors undergo wide excision and no longer require anatomical compartmental resection unless this is dictated by tumor location. Radiotherapy plays a key role in the local control of the tumor. It too is the subject of vigorous investigation of the optimal timing and dose and the effects on patient outcome and satisfaction. For example, patients treated with postoperative radiation have fewer wound complications than those treated before surgery.⁶ Despite improved early functional status in those irradiated after surgery, outcomes ultimately seem equivalent.⁷

These issues are not mundane. If we are to offer patients less surgery, anticipating equivalent survival but better QOL outcomes, then we need to be mindful of the alternatives and the consequences of the treatment prescribed for their care. Many surgeons consider amputation if sacrifice of the sciatic nerve is required. However, we have shown, in the lower extremity at least, that even sacrifice of such a major functional nerve leads to acceptable function, and with forethought in planning, local excision is a worthy alternative to amputation.⁸ Major vascular and soft tissue reconstructions have also allowed us to extend the limits of "local resection." Ghert et al.⁵ did show that the upper extremity tolerates neurovascular resection less well than the lower extremity, thus leading to a relatively higher rate of amputation for tumors located there. Having a multidisciplinary surgical team consisting of surgical oncologists, orthopedic oncologists, vascular surgeons, and plastic surgeons is imperative to success in functional and oncological outcomes. Tertiary referral for treatment of these tumors would seem an obvious choice.

Nevertheless, there is a definite place for radical extirpative surgery in the armamentarium of the surgical oncologist. Patients with large breast tumors invading the chest wall may still require a Halstead radical mastectomy; persistent or recurrent laryngeal tumors require laryngectomy; and bulky or deeply invasive anorectal melanomas necessitate abdominoperineal resections. We all recognize these indications, even at the expense of higher morbidity and perceived decrements in QOL for these patients, when compared with lesser procedures. However, interest in palliative surgery has undergone a recent resurgence. In terms of extremity soft tissue sarcoma, in a select series, most patients undergoing palliative forequarter amputations had improvements in their preoperative Karnofsky performance status and QOL.⁹ Therefore, as demonstrated by Ghert et al.⁵, even in this era of "less is more," "more" surgery is appropriate in select cases.

Received for publication September 27, 2004. Accepted for publication October 18, 2004.

REFERENCES

1. Rosenberg SA, Tepper J, Glatstein E, et al. The treatment of soft-tissue sarcomas of the extremities: prospective randomized evaluations of (1) limb-sparing surgery plus radiation therapy compared with amputation and (2) the role of adjuvant chemotherapy. Ann Surg 1982;196:305–15.[Medline]
2. Fisher B, Anderson S, Redmond CK, et al. Reanalysis and results after 12 years of follow-up in a randomized clinical trial comparing total mastectomy with lumpectomy with or without irradiation in the treatment of breast cancer. N Engl J Med 1995;333:1456–61.[Abstract/Free Full Text]
3. Induction chemotherapy plus radiation compared with surgery plus radiation in patients with advanced laryngeal cancer. The Department of Veterans Affairs Laryngeal Cancer Study Group. N Engl J Med 1991;324:1685–90.[Abstract]
4. Droesch J, Flum DR, Mann GN. Wide local excision or abdominoperineal resection as the initial treatment for anorectal melanoma? Am J Surg 2005 (in press).
5. Ghert MA, Abudu A, Driver N, et al. The indications for and the prognostic significance of amputation as the primary surgical procedure for localized soft tissue sarcoma of the extremity. Ann Surg Oncol 2005;12:(in press).
6. O’Sullivan B, Davis AM, Turcotte R, et al. Preoperative versus postoperative radiotherapy in soft-tissue sarcoma of the limbs: a randomized trial. Lancet 2002;359:2235–41.[CrossRef][Medline]
7. Davis AM, O’Sullivan B, Bell RS, et al. Function and health status outcomes in a randomized trial comparing preoperative and postoperative radiotherapy in extremity soft tissue sarcoma. J Clin Oncol 2002;20:4472–7.[Abstract/Free Full Text]
8. Brooks AD, Gold JS, Graham D, et al. Resection of the sciatic, peroneal, or tibial nerves: assessment of functional status. Ann Surg Oncol 2002;9:41–7.[Abstract/Free Full Text]
9. Merimsky O, Kollender Y, Inbar M, et al. Is forequarter amputation justified for palliation of intractable cancer symptoms? Oncology 2001;60:55–9.[Medline]

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